Provider Demographics
NPI:1104218510
Name:ELTING, NICOLE MICHELLE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MICHELLE
Last Name:ELTING
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CLOCK TOWER CMNS
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-4055
Mailing Address - Country:US
Mailing Address - Phone:845-592-4915
Mailing Address - Fax:
Practice Address - Street 1:159 BARNEGAT RD FL 2
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-5401
Practice Address - Country:US
Practice Address - Phone:845-452-9800
Practice Address - Fax:845-452-7691
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY531856-1163W00000X
NYF338948-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMEDICAIDMedicaid
NYMEDICARE PINMedicare PIN
NYMEDICAIDMedicare UPIN